HospitalInspections.org

Based on interview and record review the facility failed to ensure prompt review and resolution in 4 of 4 patient grievances in a timely manner.
This deficient practice had the likelihood to cause harm in all patients.
Findings include:
Review of the facility complaint and grievance log revealed the following complaints:
04/01/2014 (date received) - Patient #1's daughter complained of poor post-operative Foley care and staff attitude. The result documented was Director of MS reeducated staff on catheter care and monitoring for bladder distention. The initial facility response was dated 04/11/2014 (10 days later). There was no documentation of when the family received their first response.
05/07/2014(date received) - Patient #1 states MD (medical director) yelled at her, would not listen to her concerns, accused her of wanting narcotics, did not examine her or her bladder. She felt he was discharging her without treatment and she felt she was at risk for further problems. The result documented was requested review by the ED (Emergency Department) medical director. The facility initial response was on 05/07/2014.
Review of the facility's first response letter to the family revealed it was dated 06/30/2014 (54 days later).
05/07/2014 (date received) - The complaint was an 18 gauge needle in patient #1's bed. The result documented was the Risk manager, Director of Surgical Services, Director of Med-surg, Surgery supervisor, all spoke with the patient and apologized. The initial facility response was documented as being 05/07/2014. There was no documentation of when the meeting with the family occurred or resolution of how the 18 gauge needle ended up in the bed. There was no documentation of a follow-up with the complainant indicating satisfaction with the apology.
07/13/2014 (date received) - Pt #1, family & guest complaint PA was unprofessional & arrogant. The result documented was the CNO referred the issue to quality with apology letter to patient. There was documentation that the initial facility response was on 07/17/2014. There was no documentation of when the family received a response.
During an interview on 08/28/2014 after 4:45 p.m., Staff #3 reported no letter was sent to the family regarding the 04/01/2014 complaint, because the issues were addressed in-house. Staff #3 confirmed the complainant letter of response on the second complaint was sent on 06/30/2014 and was late. The third complainant should have been sent a response letter and this was not done. There was no follow-up done to see if the complainant was satisfied. The complaint dated 07/13/2014 had no documentation of an investigation nor was there a response letter sent to the family.
Review of the "Patient Complaints/Grievances" policy dated 07/2012 revealed the following:
"Patient Complaint" means an oral or written expression of displeasure or dissatisfaction with service received that can be immediately resolved by the staff present.
"Patient Grievance" means an oral or written complaint that is not immediately resolved at the time of the complaint by staff present. A Patient Grievance may be made by the patient or the patient's representative regarding, but not limited to, the patient's care, abuse or neglect ... A written complaint is always considered a grievance and may be submitted by fax or email. Whenever the patient or the patient's representative requests that the complaint be handled as a formal complaint or grievance, or when the patient requests a response from the hospital, then complaint is a grievance."
Whether a patient/family grievance is received by hospital staff in person, by telephone or in writing, a Patient and Family Complaint/Grievance report shall be originated by staff receiving the grievance. The staff shall forward the Patient and Family Complaint/Grievance report to the manager/director of the affected department for investigation and resolution as well as a copy to the Nursing Administration.
If the grievance is determined by the manager/director to be a patient rights violation or standard of care breach, the manager/director shall forward a copy of the Patient and Family Complaint\Grievance report to the Director, Clinical Quality Improvement (DCQI) or that Risk manager(RM) for action. The DQI/RM shall enact the bill hold process and complete an event hold process and complete an event report ... ....
The manager/director will complete the investigation and confer with the Grievance Committee concerning the results and the planned response. If the resolution of the Grievance is determined to take longer than seven days, the Grievance committee will send a response to the patient informing him/her that the Hospital is still working to resolve the grievance and that the Hospital will follow-up with a written response within a stated number of days. No more than seven days will elapse before a response is sent to the patient. The final response letter shall be approved by the Hospital's claims representative when possible.
Each issue defined as a Grievance will be followed up with a written notice of decision from the manager/director. The written response will contain the following elements;
*Date of receipt of Grievance
*Name of the Hospital contact person for patient follow up if needed
*Steps taken to investigate and dates completed
*Results of investigation and dates completed
*Completion date
A Grievance is considered resolved when the patient is satisfied with the actions taken on his/her behalf. When there are situations where the Hospital has taken appropriate and responsible actions to resolve the Grievance and the patient remains unsatisfied, the Hospital considers the Grievance closed. All documentation of patient communication will be maintained by hospital Quality Management.

Based on interview and record review the facility failed to ensure patients were provided with notice of status of grievances in 4 of 4 patient grievances.
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

Review of the facility complaint and grievance log revealed the following complaints:
04/01/2014 (date received) - Patient #1's daughter complained of poor post-operative Foley care and staff attitude. The result documented was Director of MS reeducated staff on catheter care and monitoring for bladder distention. The initial facility response was dated 04/11/2014 (10 days later). There was no documentation of when the family received a received their first response.
05/07/2014(date received) - Patient #1 states MD (medical director) yelled at her, would not listen to her concerns, accused her of wanting narcotics, did not examine her or her bladder. She felt he was discharging her without treatment and she felt she was at risk for further problems. The result documented was requested review by the ED (Emergency Department) medical director. The facility initial response was on 05/07/2014.
Review of the facility's first response letter to the family revealed it was dated 06/30/2014 (54 days later).
05/07/2014 (date received) - The complaint was an 18 gauge needle in patient #1's bed. The result documented was the Risk manager, Director of Surgical Services, Director of Med-surg, Surgery supervisor, all spoke with the patient and apologized. The initial facility response was documented as being 05/07/2014. There was no documentation of when the meeting with the family occurred or resolution of how the 18 gauge needle ended up in the bed. There was no documentation of a follow-up with the complainant indicating satisfaction with the apology.
07/13/2014 (date received) - Pt #1, family & guest complaint PA was unprofessional & arrogant. The result documented was the CNO referred the issue to quality with apology letter to patient. There was documentation that the initial facility response was on 07/17/2014. There was no documentation of when the family's response was sent.
During an interview on 08/28/2014 after 4:45 p.m., Staff #3 reported no letter was sent to the family regarded the 04/01/2014 complaint, because the issues were addressed in-house. Staff #3 confirmed the complainant letter of response on the second complaint was sent on 06/30/2014 and was late. The third complainant should have been sent a response letter and this was not done. There was no follow-up done to see if the complainant was satisfied. The complaint dated 07/13/2014 had no documentation of an investigation nor was there a response letter sent to the family.
Review of the "Patient Complaints/Grievances" policy dated 07/2012 revealed the following:
"Patient Complaint" means an oral or written expression of displeasure or dissatisfaction with service received that can be immediately resolved by the staff present.
"Patient Grievance" means an oral or written complaint that is not immediately resolved at the time of the complaint by staff present. A Patient Grievance may be made by the patient or the patient's representative regarding, but not limited to, the patient's care, abuse or neglect ... A written complaint is always considered a grievance and may be submitted by fax or email. Whenever the patient or the patient's representative requests that the complaint be handled as a formal complaint or grievance, or when the patient requests a response from the hospital, then complaint is a grievance."
Whether a patient/family grievance is received by hospital staff in person, by telephone or in writing, a Patient and Family Complaint/Grievance report shall be originated by staff receiving the grievance. The staff shall forward the Patient and Family Complaint/Grievance report to the manager/director of the affected department for investigation and resolution as well as a copy to the Nursing Administration.
If the grievance is determined by the manager/director to be a patient rights violation or standard of care breach, the manager/director shall forward a copy of the Patient and Family Complaint\Grievance report to the Director, Clinical Quality Improvement (DCQI) or that Risk manager(RM) for action. The DQI/RM shall enact the bill hold process and complete an event hold process and complete an event report ... ....
The manager/director will complete the investigation and confer with the Grievance Committee concerning the results and the planned response. If the resolution of the Grievance is determined to take longer than seven days, the Grievance committee will send a response to the patient informing him/her that the Hospital is still working to resolve the grievance and that the Hospital will follow-up with a written response within a stated number of days. No more than seven days will elapse before a response is sent to the patient. The final response letter shall be approved by the Hospital's claims representative when possible.
Each issue defined as a Grievance will be followed up with a written notice of decision from the manager/director. The written response will contain the following elements;
*Date of receipt of Grievance
*Name of the Hospital contact person for patient follow up if needed
*Steps taken to investigate and dates completed
*Results of investigation and dates completed
*Completion date
A Grievance is considered resolved when the patient is satisfied with the actions taken on his/her behalf. When there are situations where the Hospital has taken appropriate and responsible actions to resolve the Grievance and the patient remains unsatisfied, the Hospital considers the Grievance closed. All documentation of patient communication will be maintained by hospital Quality Management.

Based on interview and record review the facility failed to ensure a medication error was reported and a root cause analysis performed on 1 of 1 patients ( Patient #1). The facility failed to ensure medication errors were reported in order for accurate quality tracking and analyzing.
This deficient practice had the likelihood to cause harm in all patients.
Findings include:
Review of Emergency Room notes revealed Patient #1 was a 76 year old female who presented on 04/30/2014 for Cerebrovascular accident and Hypertensive Emergency. According to the notes, Patient #1 was admitted to the medical/surgical floor.
Review of a "Report Form" dated 05/02/2014, revealed Patient #1 was admitted to Intensive Care Unit at 11:30 p.m... and the reason was not documented. Review of a "Report Form" dated 05/05/2014 revealed the following: Patient #1 "Was upstairs and going home on Friday. BP meds got messed up and BP bottomed out. Tx to ICU for hypotension."
During an interview on 08/28/2014 after 2:00 p.m., Staff #4 (Director of Medical-Surgical unit) reported not knowing anything about problems with the blood pressure medication on Patient #1.
During an interview on 08/28/2014 after 4:45 p.m., Staff #3 (Director of Quality) reported having no root cause analysis on the incident. Staff #3 reported a facility event report had not been completed by staff on the incident.
Review of a facility policy named "Event Reporting" dated 11/12/2013 revealed the following:
"Reportable Event" means an event that is not consistent with the routine operation of the Hospital or the routine care of a patient or patients. The potential for accident, injury, illness or property damage commonly referred to as a "Near Miss" is sufficient for an event to be considered a Reportable Event. Reportable Events may also include an unintended event or act of omission or commission that departs from or fails to achieve what was intended or a serious adverse event involving research study patients ... Reportable Events may or may not result in negative consequences to the patient. Reportable Events may include a system error, or an individual error of judgment of action or inaction.
Any Hospital Staff Member who witnesses, discovers or has direct involvement in and /or knowledge of a Reportable Event must complete an Event Report. More than one individual may complete a report concerning the same issue. Members of the Medical Staff may complete an Event Report or request that another Hospital Staff Member with direct knowledge of the event complete the form.
Time Frame for Completing an Event Report
After providing for the needs of the individuals involved, Hospital Staff Members must complete and submit an Event Report in DSRM (Electronic Safety and Risk Management on-line reporting) as soon as possible. Preferably, the report should be submitted before leaving the Hospital at the end of the work shift, but no later than twenty-four (24) hours from the time the event occurred.
Quality Management will audit the Hospital's compliance with this policy as part of its Comprehensive Clinical Audits. Audit Services will audit the Hospital's compliance with this policy as part of its routine audits.
Review of the policy named "Conducting a Root Cause Analysis (RCA) dated 12/21/2012 revealed the following:
A.Critical Incidents and Events Requiring Root Cause Analyses
The Hospital shall conduct an RCA on any incident meeting the definition of the following:
2. An unexpected event which could potentially lead to a serious adverse patient outcome.
B.Process for Completing the Root Cause Analysis and Action Plan
1. Any potential or actual event must have a thorough and credible RCA completed within 14 days from the date of the event.

Based on interview and record review the facility failed to:

A. ensure registered nurses evaluated patients prior to and after administration of blood pressure medications in 3 of 3 patients (Patient #s' 1, 8 and 11). The facility failed to ensure an accurate and complete assessment was performed timely in the area of nutrition and on surgical sites in 1 of 1 patients (Patient #1).
Refer to A0395 for additional information.



B. ensure patients at risk for skin breakdown were turned and repositioned as planned in 3 of 3 sampled patients (Patient #s'1, 5 and 7).
Refer to A0396 for additional information.



C. ensure timely medication administration and timely monitoring by nurses prior to and after administration of blood pressure medications in 3 of 3 patients (Patient #s' 1, 8 and 11).

Refer to A0405 for additional information.

Based on interview and record review the facility failed to ensure registered nurses evaluated patients prior to and after administration of blood pressure medications in 3 of 3 patients (Patient #s' 1, 8 and 11). The facility failed to ensure an accurate and complete assessment was performed timely in the area of nutrition and on surgical sites in 1 of 1 patients (Patient #1).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:
Review of Emergency Room (ER) notes revealed Patient #1 was a 76 year old female who presented on 04/30/2014 at 2:01 p.m. with diagnoses of Cerebrovascular accident and Hypertensive Emergency.
Review of the ER notes revealed the first documentation of a blood pressure was at 2:19 p.m. (18 minutes after presenting). At 3:25 p.m. (over an hour later) the first dose of blood pressure medication Hydralazine 10 milligrams intravenous was administered. At 3:31 p.m. the blood pressure was still elevated at 215/87; at 3:52 p.m. it was 197/81 and at 4:48 p.m. it was 194/97. The next dose of blood pressure medication (Labetalol 5 milligrams) was administered at 5:03 p.m. According to the ER notes Patient #1 was admitted to a telemetry bed at 5:23 p.m. and left the ER at 6:06 p.m.
Review of an Emergency Department Report Form (communication tool used for nurses from different units) revealed report was given by an ED nurse, but it did not indicate who was talked to. There was no documentation of what the oxygen saturation was, pain level or if the form was faxed.
Review of the nursing assessment dated 04/30/2014 after admission to the medical/surgical unit revealed an incomplete nutritional assessment. The section to indicate difficulty swallowing was not selected and the nurse selected "0" request for nutritional consult. The dysphagia screen while in the ER revealed Patient #1 failed the screen and was made NPO (nothing by mouth). Review of a nursing assessment dated 05/03/2014 revealed an order was written for a dietary consult as a result of a Braden scale assessment.
Review of a medication administration sheet revealed Patient #1 was on the following blood pressure medications from 04/30/2014-05/02/2014:
*Norvasc 5 milligrams daily started on 04/03/2014;and another one time 5mg dose of Norvasc was ordered on 05/02/2014 at 10:29 a.m.
*Hydralazine 10 milligrams by mouth QID (four times a day) started on 04/30/2014 and discontinued on 05/01/2014. On 05/01/2014 Hydralazine 25 milligrams, one by mouth TID (three times a day) was ordered. On 05/02/2014 at 7:39 p.m. Hydralazine 50 milligrams, dosage of two by mouth TID.
*Clonidine 0.3 milligrams/24 hours patch, trans dermally every 7 days.
*Lisinopril 20 milligrams daily.
*Coreg 12.5 milligrams twice a day.

Review of vital signs on 05/02/2014 revealed the following:
8:14 a.m., blood pressure was 166/66;
11:57 a.m., blood pressure was 186/94;
4:13 p.m., blood pressure was 169/83, 4:18 p.m., blood pressure was 186/94 and at 4:19 p.m., the blood pressure was 186/94;
Review of the medication administration records dated 05/02/2014 revealed Patient #1 received the one time extra dose of Norvasc 5mg that was ordered at 10:29 a.m. was administered at 5:21 p.m. (7 hours later). The 2:00 p.m. dose of Hydralazine 25 milligrams was administered at 4:18 p.m. (2 hours late).
Review of vital signs revealed at 8:19 p.m., the blood pressure was 198/100 and at 9:24 p.m., the blood pressure was 198/100.
Review of the medication administration record dated 05/02/2014, at 9:24 p.m. an increased dosage of Hydralazine 50 milligrams, Lisinopril 20 milligrams, and Coreg at 9:24 p.m. were administered
Review of vital signs on 05/02/2014 revealed the following decrease in blood pressure an hour later:
10:24 p.m., blood pressure was 140/71 and at 10:45 p.m., the blood pressure was 121/58.
11:00 p.m., blood pressure was 103/51, 11:25 p.m., blood pressure was 113/53, and 11:45 p.m., blood pressure was 119/49
Review of a "Rapid Response Team Record" dated 05/02/2014, at 10:28 p.m-11:30 p.m... revealed the floor nurse was called to the room by the family. Patient #1 was on the bedside commode, became less alert and then non-responsive. Patient #1 was transferred the Intensive Care Unit (ICU) for a higher level of care.
Review of a "Report Form" dated 05/02/2014; revealed Patient #1 was admitted to Intensive Care Unit at 11:30 p.m... and the reason was not documented.
Review of a "Report Form" dated 05/05/2014 revealed the following: "Was upstairs and going home on Friday. BP meds got messed up and BP bottomed out. Tx to ICU for hypotension." The form indicated a report was given, but there was no documentation of what nursing on the medical -surgical unit it was given to nor if it was faxed.

Review of "Surgical Documentation" dated 05/07/2014 revealed Patient #1 sent for a percutaneous esophagastroscopy tube placement at 12:17 p.m. and the procedure was over at 12:29 p.m...
Review of an undated "Report Form" revealed Patient #1 was discharged to the floor from surgery at 1:09 p.m.
Review of nursing assessments revealed the first documentation of an assessment of Patient #1's incision site or dressing was at 8:10 p.m. (7 hours after returning to the floor).
During a confidential interview it was reported Patient #1 was soiled with blood and had no dressing over her incision site after returning from surgery.
During an interview on 08/28/2014 after 2:00 p.m., Staff #4 confirmed Patient #1 did not have a dressing over her incision site after surgery. The patient had a small amount of blood on her gown. Normal hospital practice was for the incision sites to be covered. Staff #4 confirmed the problems with the blood pressure medications being given late, nutritional assessment and the documentation of the late response in the ER.
During an interview on 08/29/2014 after 9:00 a.m., Staff #12 confirmed the problems with the blood pressure medication being administered late. Staff #12 confirmed the missing assessment on the incision site after surgery. She reported they did not normally assess the surgical site immediately after returning from surgery.

Review of a Medication Order sheet revealed Patient #8 was a 63 year old male admitted on 08/27/2014 with a diagnosis of Malignant Hypertension.
Review of medication orders dated 08/27/2014 revealed one of the following blood pressure medications listed:
Clonidine 0.4 milligrams, one tab SL (sublingually), no frequency was documented.
Review of the medication administration record dated 08/28/2014 revealed the medication was listed the following:
Clonidine (Catapress) 0.3 milligrams = 3, tab oral, every 6 hours, Hold for sbp (systolic blood pressure) <140
Review of a vital sign flow sheet revealed Patient #8 had a blood pressure of 127/54 at 3:15 p.m...
Review of the medication administration record dated 08/28/2014 revealed at 6:00 p.m. (45 minutes after the documented blood pressure), the Clonidine was held by nursing. There was documentation of a reason for holding the medication nor documentation of another blood pressure being taken immediately before the 6:00 p.m. dose.
Review of the vital sign flow sheet dated 08/28/2014 revealed the following documented blood pressures:
6:26 p.m. - 145/61 (30 minutes after holding the 6:00 p.m. scheduled dose)
8:25 p.m. -155/68 (over 2 hours after holding the 6:00 p.m. scheduled dose)

Review of a medication administration record dated 08/28/2014 revealed Patient #11 was a 49 year old female admitted on 08/25/2014 with a diagnosis of cardiomyopathy.
According to the medication administration record Patient #11 was on the blood pressure agents used for hypertension:
Lisinopril 2.5 milligrams=0.5 tab daily, Please hold for SBP (systolic blood pressure) < 100
Carvedilol 3.125 milligrams =1 tab oral, daily (9:00 a.m.), Please hold for SBP (systolic blood pressure) < 100

Furosemide 20 milligrams =1 tab, oral, daily, Please hold for SBP (systolic blood pressure) < 110
Patient #11 also had the hypotensive agent Midodrine 10 milligrams=2 tab, oral, TID (three times a day).
Review of the vital sign flow sheet revealed at 4:00 a.m. Patient #11 had a blood pressure of 102/55. There was no other documented blood pressure before 8:12 a.m.
Review of the medication administration record revealed all the blood pressure medications were administered at 8:12 a.m. (4 hours after the last documented blood pressure).
Review of the vital sign flow sheet revealed the documented blood pressure was at 8:33 a.m. And it was 101/63. There was no documentation of another blood pressure until 12:54 p.m. (over 4 hours later) and it had dropped to 71/49.
All medications were errors because they were given prior to a documented blood pressure and staff did not follow the parameters.
During an interview on 08/29/2014 after 10:00 a.m., Staff #12 confirmed the way the medications were being administered.

Review of a facility policy named "Nurses' Admission and Assessment" dated 02/2010 revealed the following:
All patients admitted the Medical-Surgical Units will have a Nurses' Admission and Assessment Record completed upon arrival to Medical-surgical Unit by a RN ...
Review of a facility policy named " eMAR Process: Medication Administration Documentation Electronically" dated 04/18/2013 revealed the following:
4. Medications are administered within the prescribed time frame or reason documented why the medication is late or not administered.
10. Assessment of clinical parameters prior to medication administration:
Certain medications require both pre- and post-administration assessment documentation of clinical parameters. The following medications and clinical assessments are required per (company name) standards:
Medication Class Assessment
Analgesics Pain
Antiperglycemics/hypoglycemic POC Blood Glucose
Antipyretics Temperature
Inotropics Heart Rate
Antihypertensives Blood Pressure

Based on interview and record review the facility failed to ensure patients at risk for skin breakdown were turned and repositioned as planned in 3 of 3 sampled patients (Patient #s'1, 5 and 7).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

Review of Emergency Room (ER) notes revealed Patient #1 was a 76 year old female who presented on 04/30/2014 at 2:01 p.m. with diagnoses of Cerebrovascular accident and Hypertensive Emergency.
Review of an "Assessment-Integumentary" note dated 05/03/2014; 1:17 a.m., revealed Patient #1 was very limited in mobility, occasionally moist, bedfast, potential problem with friction and shear, and probably inadequate nutrition. According to the note the plan was to initiate a turning schedule. Turn and reposition patient at least every 2 hours.
Review of an "Assessment ADL" (Activities of Daily Living) and "Assessment-Integumentary" flow sheets revealed some of the following examples of turning:
05/03/2014- 1:17 a.m., 418a.m., 4:20 a.m., 6:40 a.m., 7:30 a.m., 9:00 a.m., 2:00 p.m., 3:44 p.m., 5:33 p.m., 8:45p.m., 9:00 p.m., and 11:00 p.m.
05/04/2014- 3:18 a.m., 7:30 a.m., 8:00 a.m., 10:30 a.m., 11:00 a.m., 12:30 p.m., 3:46 p.m., and 5:32 p.m.
The next documentation found for turning was on 05/05/2014 at 7:30 a.m. (over 13 hours later).
There were time frames which went over 2 hours.



Review of an "Assessment ADL" note revealed Patient #5 was an 89 year old male admitted on 08/21/2014.
Review of an "Assessment-Integumentary" note dated 08/25/2014 revealed Patient #5 was slightly limited in mobility, occasionally moist, potential problem with friction and shear, and probably inadequate nutrition. According to the notes the plan was to turn and reposition patient at least every 2 hours.
Review of an "Assessment ADL" flow sheet revealed the on 08/28/2014 between 5:30 a.m. to 12:35 p.m. (7 hour time frame) there was no documentation of turning.

Review of an "Assessment ADL" notes revealed Patient #7 was a 64 year old male admitted on 08/23/2014.
Review of an "Assessment -Integumentary" note dated 08/25/2014, 7:15 p.m. revealed Patient #7 was slightly limited in mobility, bedfast and nutrition probably inadequate. According to the notes the plan was to turn and reposition patient at least every 2 hours.
Review of an "Assessment-ADL" and Assessment -Integumentary" flow sheet revealed some of the following examples of documented turning:
08/26/2014- 9:28 a.m., 1:23 p.m., 3:28 p.m., 7:00 p.m., 9:56p.m.
08/27/2014 at 12:04 a.m., 3:00 a.m., 3:49a.m., 7:15 a.m., 9:00 a.m., 11:15 a.m. 1:00 p.m., 9:30 p.m.,
08/28/2014 at 12:35 a.m.
There were time frames which went over 2 hours.
During an interview on 08/29/2014 after 8:30 a.m., Staff #3 confirmed the problems with documentation of turning.

Review of a facility policy named "Nurses' Admission and Assessment" dated 02/2010 revealed the following:
All patients admitted the Medical-Surgical Units will have a Nurses' Admission and Assessment Record completed upon arrival to Medical-surgical Unit by a RN.
Registered Nurses assess, plan, direct, and evaluate all patient care..

Based on interview and record review the facility failed to ensure timely medication administration and timely monitoring by nurses prior to and after administration of blood pressure medications in 3 of 3 patients (Patient #s' 1, 8 and 11).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:
Review of Emergency Room (ER) notes revealed Patient #1 was a 76 year old female who presented on 04/30/2014 at 2:01 p.m. with diagnoses of Cerebrovascular accident and Hypertensive Emergency.
Review of the ER notes revealed the first documentation of a blood pressure was at 2:19 p.m. (18 minutes after presenting). At 3:25 p.m. (over an hour later) the first dose of blood pressure medication Hydralazine 10 milligrams intravenous was administered. At 3:31 p.m. the blood pressure was still elevated at 215/87; at 3:52 p.m. it was 197/81 and at 4:48 p.m. it was 194/97. The next dose of blood pressure medication (Labetalol 5 milligrams) was administered at 5:03 p.m. According to the ER notes Patient #1 was admitted to a telemetry bed at 5:23 p.m. and left the ER at 6:06 p.m.
Review of an Emergency Department Report Form (communication tool used for nurses from different units) revealed report was given by an ED nurse, but it did not indicate who was talked to. There was no documentation of what the oxygen saturation was, pain level or if the form was faxed.
Review of a medication administration sheet revealed Patient #1 was on the following blood pressure medications from 04/30/2014-05/02/2014:
*Norvasc 5 milligrams daily started on 04/03/2014;and another one time 5mg dose of Norvasc was ordered on 05/02/2014 at 10:29 a.m.
*Hydralazine 10 milligrams by mouth QID (four times a day) started on 04/30/2014 and discontinued on 05/01/2014. On 05/01/2014 Hydralazine 25 milligrams, one by mouth TID (three times a day) was ordered. On 05/02/2014 at 7:39 p.m. Hydralazine 50 milligrams, dosage of two by mouth TID.
*Clonidine 0.3 milligrams/24 hours patch, trans dermally every 7 days.
*Lisinopril 20 milligrams daily.
*Coreg 12.5 milligrams twice a day.

Review of vital signs on 05/02/2014 revealed the following:
8:14 a.m., blood pressure was 166/66;
11:57 a.m., blood pressure was 186/94;
4:13 p.m., blood pressure was 169/83, 4:18 p.m., blood pressure was 186/94 and at 4:19 p.m., the blood pressure was 186/94;
Review of the medication administration records dated 05/02/2014 revealed Patient #1 received the one time extra dose of Norvasc 5mg that was ordered at 10:29 a.m. was administered at 5:21 p.m. (7 hours later). The 2:00 p.m. dose of Hydralazine 25 milligrams was administered at 4:18 p.m. (2 hours late).
Review of vital signs revealed at 8:19 p.m., the blood pressure was 198/100 and at 9:24 p.m., the blood pressure was 198/100.
Review of the medication administration record dated 05/02/2014, at 9:24 p.m. an increased dosage of Hydralazine 50 milligrams, Lisinopril 20 milligrams, and Coreg at 9:24 p.m. were administered
Review of vital signs on 05/02/2014 revealed the following decrease in blood pressure an hour later:
10:24 p.m., blood pressure was 140/71 and at 10:45 p.m., the blood pressure was 121/58.
11:00 p.m., blood pressure was 103/51, 11:25 p.m., blood pressure was 113/53, and 11:45 p.m., blood pressure was 119/49
Review of a "Rapid Response Team Record" dated 05/02/2014, at 10:28 p.m-11:30 p.m... revealed the floor nurse was called to the room by the family. Patient #1 was on the bedside commode, became less alert and then non-responsive. Patient #1 was transferred the Intensive Care Unit (ICU) for a higher level of care.
Review of a "Report Form" dated 05/02/2014; revealed Patient #1 was admitted to Intensive Care Unit at 11:30 p.m... and the reason was not documented.
Review of a "Report Form" dated 05/05/2014 revealed the following: "Was upstairs and going home on Friday. BP meds got messed up and BP bottomed out. Tx to ICU for hypotension." The form indicated a report was given, but there was no documentation of what nursing on the medical -surgical unit it was given to nor if it was faxed.
During an interview on 08/28/2014 after 2:00 p.m., Staff #4 confirmed the problems with the blood pressure medications being given late and the documentation of the late response in the ER.
During an interview on 08/29/2014 after 9:00 a.m., Staff #12 confirmed the problems with the blood pressure medication being administered late.

Review of a Medication Order sheet revealed Patient #8 was a 63 year old male admitted on 08/27/2014 with a diagnosis of Malignant Hypertension.
Review of medication orders dated 08/27/2014 revealed one of the following blood pressure medications listed:
Clonidine 0.4 milligrams, one tab SL (sublingually), no frequency was documented.
Review of the medication administration record dated 08/28/2014 revealed the medication was listed the following:
Clonidine (Catapress) 0.3 milligrams = 3, tab oral, every 6 hours, Hold for sbp (systolic blood pressure) <140
Review of a vital sign flow sheet revealed Patient #8 had a blood pressure of 127/54 at 3:15 p.m...
Review of the medication administration record dated 08/28/2014 revealed the 6:00 p.m. (45 minutes after the documented blood pressure) the Clonidine was held by nursing. There was documentation of a reason for holding the medication nor documentation of another blood pressure being taken immediately before the 6:00 p.m. dose.
Review of the vital sign flow sheet dated 08/28/2014 revealed the following documented blood pressures:
6:26 p.m. - 145/61 (30 minutes after holding the 6:00 p.m. scheduled dose)
8:25 p.m. -155/68 (over 2 hours after holding the 6:00 p.m. scheduled dose)

Review of a medication administration record dated 08/28/2014 revealed Patient #11 was a 49 year old female admitted on 08/25/2014 with a diagnosis of cardiomyopathy.
According to the medication administration record Patient #11 was on the blood pressure agents used for hypertension:
Lisinopril 2.5 milligrams=0.5 tab daily, Please hold for SBP (systolic blood pressure) < 100
Carvedilol 3.125 milligrams =1 tab oral, daily (9:00 a.m.), Please hold for SBP (systolic blood pressure) < 100

Furosemide 20 milligrams =1 tab, oral, daily, Please hold for SBP (systolic blood pressure) < 110
Patient #1 also had the hypotensive agent Midodrine 10 milligrams=2 tab, oral, TID (three times a day).
Review of the vital sign flow sheet revealed at 4:00 a.m. Patient #11 had a blood pressure of 102/55. There was no other documented blood pressure before 8:12 a.m.
Review of the medication administration record revealed all the blood pressure medications were administered at 8:12 a.m. (4 hours after the last documented blood pressure).
Review of the vital sign flow sheet revealed the documented blood pressure was at 8:33 a.m. And it was 101/63. There was no documentation of another blood pressure until 12:54 p.m. (over 4 hours later) and it had dropped to 71/49.
All medications were errors because they were given prior to a documented blood pressure and staff did not follow the parameters.
During an interview on 08/29/2014 after 10:00 a.m., Staff #12 confirmed the way the medications were being administered.

Review of a facility policy named "Nurses' Admission and Assessment" dated 02/2010 revealed the following:
All patients admitted the Medical-Surgical Units will have a Nurses' Admission and Assessment Record completed upon arrival to Medical-surgical Unit by a RN ...
Review of a facility policy named " eMAR Process: Medication Administration Documentation Electronically" dated 04/18/2013 revealed the following:
4. Medications are administered within the prescribed time frame or reason documented why the medication is late or not administered.
10. Assessment of clinical parameters prior to medication administration:
Certain medications require both pre- and post-administration assessment documentation of clinical parameters. The following medications and clinical assessments are required per (company name) standards:
Medication Class Assessment
Analgesics Pain
Antiperglycemics/hypoglycemic POC Blood Glucose
Antipyretics Temperature
Inotropics Heart Rate
Antihypertensives Blood Pressure